Friday, March 23, 2007

Multiple options available for treatment of MRSA

Management of Staphylococcus aureus Infections - December 15, 2005 -- American Family Physician

More than half of all patients who develop S. aureus infections while in the hospital are found to have MRSA (methicillin resistant Staph. aureus). Vancomycin is the drug of choice in the treatment of MRSA. With the development of vancomycin resistant strains, it is important for physicians and patients to be aware of alternatives to vancomycin. Luckily, there are several alternatives available.

A fairly recent review article from American Family Physician (AFP), summarizes these alternatives. Linezolid (Zyvox) can be used for all types of MRSA infections, but is especially useful in treating hospital acquired MRSA pneumonia. One article found that it was actually superior to Vancomycin in this setting. Daptomycin (Cubicin) can be used for all complicated MRSA infections EXCEPT pneumonia.

Patients who develop simple MRSA skin infections outside of the hospital can usually be treated with trimethoprim/sulfamethoxazole (Bactrim), doxycycline,
or possibly a fluoroquinolone such as gati- or levofloxicin.

In patients found to have methacillin susceptible S. aureus (MSSA), the treatment should be easier. Oral dicloxacillin or IV nafcillin or oxacillin (known as semi-synthetic penicillins) are preferred. Oral cephalexin (Keflex) or IV cefazolin (Ancef) (known as 1st generation cephalosporins) are a good alternative. In this setting, Vancomycin should be reserved for patients who are allergic to penicillins.

The article goes on to describe aspects of treatment specific to the various body systems that may be infected by S. aureus. ...very good reading.

Friday, March 02, 2007

Multifactorial approach effective for treatment of IBS

Treatment of Irritable Bowel Syndrome - December 15, 2005 -- American Family Physician

Using an algorithm adapted from a New England Journal of Medicine article, a recent review in AFP promotes a multi factorial approach to the treatment of Irritable Bowel Syndrome (IBS). In addition to relaxation, stress reduction, education, and exercise, patients with mild IBS usually respond to dicyclomine (an antispasmodic) and peppermint. Patients with constipation do especially well with the addition of guar gum, fiber, exercise, and/or laxatives. Those who suffer from diarrhea or pain usually respond to the addition of immodium and TCAs (tricyclic antidepressants). Other treatments, including, 5-HT3 antagonists (Alosetron), 5-HT4 agonists (Tegaserod, or Zelnorm), Cisapride, probiotics, or cognitive-behavioral therapy, can be tried if other therapies fail.

Peppermint is especially interesting because it works well in several ways. It is an antispasmodic, anesthetic, and relieves nausea. As an herbal, it can be given over the counter or as a tea. Importantly, it may be acceptable to many patients who are hesitant to start a new 'medication'.

For those with constipation, guar gum is interesting for much the same reason as pepperment. It too can be given over the counter, and, importantly, patients tend to actually like it better than fiber.

Patients with diarrhea have two very good choices. We all know immodium, but it is important to know that it does suprisingly well in the treatment of IBS. In addition, TCAs such as desipramine (my favorate), amitryptyline, and clomipramine, work very well in low doses. Patients should know that the mechanism of action for TCA's is likely seperate from that which is involved in the antidepressant quality of the drugs (and thus you are NOT saying that they are crazy when prescribing the medication).

In short, patients with IBS have no reason to go untreated. There exist multiple good therapies, and good understanding and treatment of the illness is achievable.

Thursday, March 01, 2007

Dipstick sufficient, no imaging necessary for uncomplicated childhood UTI's

Urinary Tract Infection in Children - December 15, 2005 -- American Family Physician

A review article in American Family Physician reports that children with uncomplicated UTI's show no benefit from imaging work-ups. While it may be true that imaging may reveal relatively common vesicourethral reflux or, less commonly, subsequent renal scarring leading to potential adult hypertension, effective treatments for these conditions are wonting, and clinical efficacy for the tests has not been shown. Older children with classic symptoms of UTI were best served by initial urine cultures and empiric antibiotics, while infants with unexplained fever and older children with nonclassic symptoms did best with initial dipstick testing.

A negative dipstick result can effectively rule out UTI. Physicians are free to treat positive cultures for as long as they want, as long as it lasts more than one day. Cranberry juice has not been shown to be effective in preventing UTI's. Although circumcision has been shown to reduce the incidence of UTI's, the benefit (from this aspect alone) is clearly insufficient to warrant the procedure.